Show Notes
Highlights:
- Establishing better balance in the face with forehead reduction surgery (1:11)
- The differences between brow lift surgery and forehead reduction surgery (2:44)
- The scar and recovery from forehead reduction surgery (3:22)
- The forehead reduction procedure itself (5:20)
- How much forehead can be reduced? (7:34)
- Hair transplant surgery as an alternative to forehead reduction surgery (8:29)
- Can you combine a forehead reduction and a brow lift? (10:10)
Links:
Dr. Jason Hall, MD
Transcript
Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I’m your host, Dr. Jason Hall.
Dr. Hall: So, today we’re going to talk about a procedure that not a lot of people know much about. And it is a procedure that has probably one of the highest patient satisfaction ratings of any procedure that we do. That procedure is forehead reduction or hairline lowering. Now, hairline lowering, or forehead reduction surgery, is exactly what it sounds like. It is a procedure that is designed to shorten an elongated forehead and effectively turn a 5 head or a 6 head into a 4 head—sorry for the bad joke.
With forehead reduction surgery, this is something that can really be life-changing for people who need it and who undergo this procedure. When we talk about forehead reduction surgery, much like every other cosmetic surgery procedure that we do, what we’re really talking about is establishing better balance of the face between the upper, the middle, and the lower thirds of the face. When we as plastic surgeons look at someone’s face and as we’re talking about things that we can do to help reestablish balance, what we’re really doing is dividing the face into thirds, vertically. And so, your upper third is hairline to eyebrows, middle third is eyebrows to the bottom of the nose, and lower third is bottom of the nose to the chin.
And when one or multiple of those vertical thirds are out of balance, it can throw off the balance of the entire face. That’s why when we’re kind of talking about things like rhinoplasty or genioplasty—chin implant surgery—that a lot of times, those procedures tend to go together. Because if the nose is a little bit too large, and the chin is a little bit too small, changing one doesn’t necessarily improve things as much as improving the overall balance of both of them. And what forehead reduction surgery does is forehead reduction surgery helps to make that upper third—so from the eyebrows to the hairline—shorter and bring it into balance with the rest of the face, if it is the part that is causing an imbalance or disharmony. Forehead reduction surgery and brow lift surgery is really almost two sides of the same coin if you want to think about it like that.
One of the differences is that with brow surgery, a lot of times modern brow lift surgery is done with an endoscope, and with forehead reduction or hairline lowering, we have to do that in an open technique. So, we make an incision and then shorten the forehead that way. A question that comes up often in the consultation is how is that surgery done and, kind of, what does it look like during healing? And one of the big drawbacks to forehead reduction surgery is that the scar for forehead reduction surgery is right at the hairline; it is very visible while it’s healing. And that scar disappears over time, so in order for this to be something that really makes sense, you have to be able to tolerate that scar while it heals.
When I do a forehead reduction, what I end up doing is making an irregular incision right at the hairline—or a little bit behind the hairline, actually—and beveling or angling that incision really steeply and that irregular incision, it looks kind of like an EKG tracing kind of a zigzag appearance to it, and that helps that scar to hide as it heals. You know, there are no straight lines—Mother Nature doesn’t make a straight line, and so a straight line scar would be very, very visible. An irregular scar breaks up the healing process and makes that less visible with time. Right after surgery, the scar is right at the hairline, it essentially makes up the frontal hairline, so it is really visible.
And as that scar heals, with that heavy beveling, hair actually grows through that scar, and so it looks like the scar actually moves back into your hairline. It kind of disappears as it heals, and that makes it much more palatable for a lot of patients. When you see these long-term results, the scar is really really tough to see because it’s behind the hairline. But during the healing process, you’ve got to deal with a scar that’s very visible. Now fortunately, once the stitches come out, you can cover that scar with concealer or makeup, and for guys, you can use a tinted sunscreen to help cover that, but that healing process for that scar to move backwards can take a couple of months and so you have to be ready for that.
How do we do a forehead reduction surgery? So, we’ll get into a little bit of a surgical details here, just so you know exactly what happens. And for people out there that are kind of students of this stuff and if there are any residents or medical students, forehead reduction surgery really borrows from principles of scalp reconstruction. What we’re doing here is making that heavily beveled incision at the hairline and then going underneath the galea—and the galea is a really tough layer of your scalp; it’s why your scalp doesn’t move around much—we go underneath the galea and actually lift that galea up all the way back to the back of the head. And then once we’ve gotten that space created, we make what are called relaxing incisions in the galea so little incisions to help open up and let that galea move a little bit, almost like opening up an accordion, and letting that forehead—or letting that hairline slide forward over the forehead.
Once we do that, then the forehead that we want to remove is marked and excised kind of in that same irregular pattern, so that that scar heals nicely and without any straight lines that will make it really visible. The important thing in closing that incision is that all of the strength of that closure is on that strong, firm, galea layer so that there is no tension on the skin. And if you’ve heard any of the other podcasts that we’ve done, you know, skin tension is kind of the enemy of good healing, especially when it comes to scars. And so, we want no tension on that skin closure. All the tension and hold needs to be on that galea layer.
There are permanent sutures that are put in through the skin that are taken out at about a week, and then like we said before, once those stitches are taken out, you can start covering that scar with concealer or makeup so that it’s not as visible. That scar starts to move back as the hair grows through the scar, and that process can take a few months, but generally, forehead reduction surgery is very well-tolerated, the scars heal very nicely. One question that comes up oftentimes is, how much forehead can be reduced? And typically with a forehead reduction surgery, we can get about two to two-and-a-half centimeters of forehead skin and remove that, advance the hairline that far. The end of my finger between the tip of my finger and my first knuckle is about two-and-a-half centimeters, so that’s a good gauge as to how much forehead can be removed.
And that’s quite a bit when you’re talking about really anything in facial surgery. You know, the old adage is, “In the face, a millimeter is a mile.” Two-and-a-half centimeters is a long way, and so that can really serve to improve balance between the, you know, upper, middle, and lower thirds of the face. The other thing that we can do to advance a hairline, to lower a hairline, is hair transplant surgery. So, if the idea of a scar across your forehead for a short time is unappealing, a hair transplant can help move your hairline forward without that scar.
Now, the downside of this is that you have to have a hair transplant. Although newer hair transplant techniques, the follicular unit extraction techniques that most hair transplant surgeons now are using are really good. You don’t have to have a scar on the back of your head, which you did with the old hair transplant techniques. And your surgeon will take this device and extract single hair follicles or little tiny groups of two or three hair follicles at a time and then plant those along your hairline to advance your hairline.
And this is a super cool technique. It’s much better than the old hair plugs that people did in the ’70s and ’80s and you can really get a nice, natural result with a newer hair transplant techniques. Now, hair transplant tends to be quite a bit more expensive than hairline advancement and it’s not something that I do, but there are surgeons whose entire practices are dedicated to hair transplant, and they would be good people to talk to if a kind of more traditional forehead reduction hairline lowering surgery isn’t something that you’re interested in. But those are really the two ways, the kind of open technique and hair transplant, that we can use to advance a hairline and shorten an elongated forehead.
Another question that I get is, can I combine a forehead reduction and a brow lift? And the answer to that is yes, kind of. They are really kind of cousins in terms of surgery; the forehead reduction hairline lowering is a cousin to the brow lift. The incisions can be the same for doing an open brow lift. The problem is that doing a brow lift and a hairline advancement is that the forces are kind of competing, you’re trying to lift a brow, you’re trying to pull a hairline forward, and each one of them want to go the opposite direction.
And you really have to be careful doing those two together that closure where all that tension is, is strong enough to be able to keep either one of those from drifting with time. And so typically, I tell patients that if you really want to have both of those procedures and need both of those procedures done at the same time, that we can do it; we have to accept a little bit of uncertainty and the possibility of a revision later, but if we can break it up and do it in two surgeries, that’s always more beneficial because each one, we can get the brow exactly right, we can get the hairline exactly right at the same time.
I hope that this has been informative. This is a short episode, but if there are any other topics that you would like to hear, please write in, let me know
info@drjasonhall.com. Thanks again for listening, and we’ll see you soon.
Dr. Hall: Thanks for listening to
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